Monday, March 18, 2013

Malar Bags

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There are 3 separate entities lower eyelid bags, festoons and malar bags.

Lower eyelid bags refers to protruding fat or redundant muscle in the lower eyelid itself above the level of the bone rim under the eye. Tear trough exaggerated by protruding eyelid fat
Lower Eyelid Bags

Festoons refers to redundant folds of skin with or without muscle in the lower eyelid.


Malar pouches, bags or saddlebags are a prominence below the level of the bone rim under the eye due some combination of swelling or edema, drooping eyelid muscle (orbicualris oculi muscle) and fat under the muscle herniating through the muscle. The lower edge of the malar bags is defined or limited by the zygomatico-cutaneous ligament which has also been called the malar septum. This ligament stops the discoloration of a black eye from spreading down into the cheeks. There is a lot of misinformation on the web regarding malar bags, even on online question boards answered by surgeons. Some people call the bags malar crescent.

The presence of malar bags can be related to previous eyelid or nose surgery independent of who your surgeon was, a complication of dermal filler injections that block normal lymphatic flow, the aging process, genetics, allergies, sinus infections, lack of sleep, water retention (related to menses, kidney insufficiency etc.), liver cirrhosis or thyroid conditions (hypo or hyperthyroidism). The chances of them appearing after dermal filler injection is reduced if smaller beads of filler are placed closer to the underlying bone and aggressive massage of the area is avoided. I get them temporarily when my allergies act up and I lose sleep.

The acute onset of malar bags such as those seen after eyelid surgery is best treated with anti-inflammatory steroids with or without diuretics and sleeping with 2 pillows under your head. Those related to allergies should first be treated with antihistamines and avoidance of inciting allergens. The injection of 20 units of Vitrase (hyaluronidase) will quickly resolve malar bags caused by injection of a hyaluronate like Restylane or Juvederm. Chronic malar bags require a medical workup to assess for one of the causes listed. That involves blood tests such as complete blood count with differential, erythrocyte sedimentation rate, serum protein electrophoresis, cryoglobulin and cryofibrinogen testing, rheumatoid factor, antinuclear antibodies, thyroid levels and liver or kidney function blood tests. A history and physical examination will inform your doctor which if any of these tests would be required..

For chronic malar bags where a medical condition is not present or has been controlled through medications surgery can be helpful. Superficial liposuction (with the cannula holes facing away from the skin) of these malar bags via a small incision near the outer corner of the eye was first described in 1984. More recently this same liposuction via an incision at the nostril rim-cheek crease and suture elevation of the muscle to the temple muscles was described.
This is a patient in whom I sutured the eyelid protruding fat to the deep cheek fat and liposcutioned fat in the malar bag between the skin and the eyelid muscle. No skin was removed. A similar though usually temporary result can be achieved using dermal filler injections.

This is a patient who underwent malar bag liposuction and muscle suture elevation elsewhere.

Nasojugal Crease - Tear Trough Deformity

Aaron Stone MD - twitter
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  1. Hi Dr Stone, I've been getting malar bags on and off for over a year now. I've had them now for weeks they won't go away it seems this time.
    I have blood work done with regular check ups and nothing out of the ordinary I'm at a loss what's causing them, the right side is more swollen than the left.
    Going to see my Dr next week to try to find a cause but not optimistic with previous bloodwork ok while I've been having this problem.
    The lady on your photo is a good example of my problem I have no under eye bags just the malar ones.
    What kind of price range was her treatment and how long is the recovery time for that procedure?
    Also I've read laser therapy may work for this problem, does that last or is that a temporary measure with this?
    I have lost a substantial amount of weight over the past twelve months 50lb. could that be a reason?

    1. Given your history of recurrent malar bags I would not recommend surgery as there is more likely something else going on. Surgery should be reserved for those who have consistent constant malar bags because recurrent malar bags are better treated medically i.e. non-surgically. The actual treatment would depend on the cause and your internist not finding the cause does not mean there is no medical reason for the problem. It just means that it has not as yet been found. Never having seen or examined you when the problem is worse and better I cannot say much more.

  2. Dr. Stone,

    I just noticed that I've developed festoons over the past few months (also coinciding with a pounding headache in between my eyes).

    Thanks to your very well written article that includes the wide range of causes for festoons, I suspect allergies or sinus issues.

    Thank so much for writing an informative article that is not alarmist - hard to find that on the Internet these days! Very grateful.

  3. Hi Dr. Stone,

    I developed malar bags a week ago and I suspected they were due to my allergies, but even after my allergies are gone the bags are still persisting. Will these bags eventually go away on their own or should I start looking into surgery? Thanks!

    1. The soft tissue changes that take place due to allergies do not resolve as quickly as the allergies themselves when you begin taking allergy medications. The medications may immediately stop the allergic reactions but it can take weeks or months before the soft tissues return to baseline or reach a new baseline.

  4. Hello is there Ány posibility glicolic ácid caúsed malar bag on my cheek?

    1. If they are truly malar bags it is highly unlikely because the malar bag occurs at a depth well below the effect of the peel.

  5. I look like I have them and they came on suddenly after I burned my skin using glycolic acid. Did the damage to the skin cause this?

    1. It can from the associated swelling but that should be temporary as deeper damage or allergies are associated with more long term malar bags.

  6. I had some hiperpigmrntation and Dr Malcolm paul did a section of my cheek w laser . However after the laser my skin turned to charcoal. I used a lot of stem cell, HQ, so thecharcol went away . But now I have malar bags. I really hate them. Not speaking to that doc anymore. I am a pretty girl w the malar bags . What should I do? I have soft Mediterranean skin. 49 year old gained also 10 pounds after surgical menopause

    1. Never having seen you I cannot make any specific recommendations but it sounds like you have 2 problems. The first sounds like melasma and the second like malar bags. You have to be careful applying hydroquinone because it can cause permanent darkening with chronic use. Treatment of the bags would depend on whether you have allergies or redundant skin. In the absence of allergies and redundant skin simple liposuction as described above should suffice.


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